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This prospective observational study aims to evaluate the ability of transthoracic echocardiographic and bedside ultrasonographic parameters to predict intradialytic hypotension and hemodynamic instability at the initiation of continuous venovenous hemodiafiltration (CVVHDF) in adult intensive care unit patients.
In critically ill patients requiring renal replacement therapy, continuous venovenous hemodiafiltration (CVVHDF) is frequently preferred due to better hemodynamic tolerance. However, initiation of CVVHDF may still lead to unpredictable intradialytic hypotension, fluid requirement, or vasopressor/inotrope support.
Bedside transthoracic echocardiography and ultrasonography provide non-invasive assessment of cardiac function, preload responsiveness, and venous congestion. Parameters such as left ventricular outflow tract velocity time integral (LVOT VTI), mitral annular plane systolic excursion (MAPSE), tricuspid annular plane systolic excursion (TAPSE), pulse pressure variation (PPV), renal resistive index (RRI), inferior vena cava (IVC) diameter, and venous excess ultrasound score (VExUS) may help predict hemodynamic tolerance to dialysis.
This study aims to evaluate the predictive value of these multimodal ultrasonographic and hemodynamic parameters for intradialytic hypotension and hemodynamic support requirement during the first 60 minutes of CVVHDF initiation.
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| Measure | Description | Time Frame |
|---|---|---|
| Hemodynamic Instability During CVVHDF Initiation | Occurrence of hypotension (mean arterial pressure <65 mmHg), requirement for fluid bolus (≥500 mL), or initiation/increase of vasopressor or inotrope support within the first 60 minutes after CVVHDF initiation. | First 60 minutes after CVVHDF initiation |
| Measure | Description | Time Frame |
|---|---|---|
| LVOT Velocity Time Integral | Measurement of left ventricular outflow tract velocity time integral obtained by transthoracic echocardiography before dialysis initiation. | Before CVVHDF initiation |
| Mitral Annular Plane Systolic Excursion (MAPSE) |
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Inclusion Criteria:
Exclusion Criteria:
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The study population consists of adult patients (aged 18 years and older) admitted to the intensive care unit of a tertiary care academic hospital who have a clinical indication for continuous venovenous hemodiafiltration (CVVHDF).
All participants are critically ill and require renal replacement therapy as part of standard clinical care. Transthoracic echocardiography and bedside ultrasonographic and hemodynamic assessments are performed as part of routine intensive care evaluation and are recorded for observational purposes only.
No healthy volunteers are included in this study. Written informed consent is obtained from the patients' legal representatives prior to study inclusion.
| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| musa h UÇAR | Contact | +905456934995 | ucarharunmusa@gmail.com |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 40219729 | Background | Cheong I. Unconventional Echocardiographic Techniques for LVOT VTI Measurement in Critical Care Settings. J Clin Ultrasound. 2025 Jul-Aug;53(6):1418-1424. doi: 10.1002/jcu.24007. Epub 2025 Apr 12. | |
| 39560910 | Background | Assavapokee T, Rola P, Assavapokee N, Koratala A. Decoding VExUS: a practical guide for excelling in point-of-care ultrasound assessment of venous congestion. Ultrasound J. 2024 Nov 19;16(1):48. doi: 10.1186/s13089-024-00396-z. |
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|---|---|
| Related Info | View source |
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| ID | Term |
|---|---|
| D051436 | Renal Insufficiency, Chronic |
| D016638 | Critical Illness |
| ID | Term |
|---|---|
| D051437 | Renal Insufficiency |
| D007674 | Kidney Diseases |
| D014570 | Urologic Diseases |
| D052776 | Female Urogenital Diseases |
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Measurement of mitral annular plane systolic excursion obtained by M-mode transthoracic echocardiography in the apical four-chamber view to assess left ventricular longitudinal systolic function prior to CVVHDF initiation.
| Before CVVHDF initiation |
| Tricuspid Annular Plane Systolic Excursion (TAPSE) | Measurement of tricuspid annular plane systolic excursion obtained by M-mode transthoracic echocardiography in the apical four-chamber view to evaluate right ventricular systolic function prior to CVVHDF initiation. | Before CVVHDF initiation |
| Pulse Pressure Variation (PPV) | Calculation of pulse pressure variation derived from invasive arterial blood pressure waveform analysis in mechanically ventilated patients to assess dynamic preload responsiveness prior to CVVHDF initiation. | Before CVVHDF initiation |
| Renal Resistive Index (RRI) | Measurement of the Renal Resistive Index (RRI), obtained by pulsed-wave Doppler ultrasonography of the segmental or interlobar renal arteries, to evaluate intrarenal vascular resistance and renal perfusion prior to initiation of continuous veno-venous hemodiafiltration (CVVHDF). The Renal Resistive Index is calculated as (peak systolic velocity - end diastolic velocity) / peak systolic velocity, with values ranging from 0 to 1. Values greater than 0.7 are considered indicative of increased intrarenal vascular resistance and poorer renal perfusion (worse outcome). | Before CVVHDF initiation |
| Inferior Vena Cava Diameter | Ultrasonographic measurement of inferior vena cava diameter obtained from the subcostal long-axis view to assess intravascular volume status prior to CVVHDF initiation. | Before CVVHDF initiation |
| Venous Excess Ultrasound Score (VExUS) | Assessment of systemic venous congestion using the Venous Excess Ultrasound Score (VExUS) prior to initiation of continuous veno-venous hemodiafiltration (CVVHDF). The Venous Excess Ultrasound Score is a grading system ranging from 0 to 3, incorporating inferior vena cava diameter and Doppler flow patterns of the hepatic, portal, and intrarenal veins. Higher scores indicate more severe systemic venous congestion and are associated with worse clinical status. | Before CVVHDF initiation |
| 35633423 | Background | Monnet X, Shi R, Teboul JL. Prediction of fluid responsiveness. What's new? Ann Intensive Care. 2022 May 28;12(1):46. doi: 10.1186/s13613-022-01022-8. |
| Related Info | View source |
| D005261 |
| Female Urogenital Diseases and Pregnancy Complications |
| D000091642 | Urogenital Diseases |
| D052801 | Male Urogenital Diseases |
| D002908 | Chronic Disease |
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |